Great news your loved one was deemed an appropriate candidate for acute inpatient rehabilitation. The patient gets hopeful that they will be able to receive the best care possible in order to go home, but then the case manager enters the room and notifies that the insurance has denied the case. Someone, sitting who knows how far away spending how many seconds (just a guess) reviewing the case has said NO. Do you think this reviewer has ever worked or stepped foot in an inpatient rehabilitation? ( I’m guessing no again) If the reviewer was considering the case for their own family member would their answer be different? ( hmmm I would wager on YES) 

How to Fight for your rights to acute inpatient rehabilitation :

1. Deep Breath, try to stay calm and be nice. You will get the best results being friendly. Yes I know it sucks having to fight in this time of stress but you will need assistance from the hospital staff. Remember you get more bees with honey.
2. Ask for a peer to peer. Officially this is a process in which a physician or other healthcare professional speaks with a representative from an insurance company to discuss the medical necessity and appropriateness of a particular treatment. In reality insurances make it very inconvenient for a physician to perform these calls. Having us call in at weird times and then placing us on hold in the middle of a busy work day. Honestly I have done these and they rarely work. In my opinion the  medical reviewer has already made up their mind before the call has begun. The insurance  rarely listens and recites vague guidelines for a denial, sounding more and more like a robot each time. Yes some insurance are more responsive to these peer to peers than others. In my experience if the patient has insurance in the naviHealth family ( Preferred Care Partner, United Health) the peer to peer results in automatic NO, with artificial intelligence playing a role. More on that later. Recordings to follow
3. File an written appeal: Submit a written appeal to your insurance company, citing the specific reasons why you believe the denial was incorrect, and including any relevant supporting documentation.  Here is where I see the most positive results. Now remember the hospital system may scare you into trying to get you to  leave using words like you will be stuck with the bill or you will lose a bed at a subacute rehab and so on and so one. It’s the case managers job to get you out of there. Another issue some physicians have to deal with is the patient length of stay. In some hospital systems physicians are monitored how long a patients is admitted and you guessed the more days the worse it looks for the physician. Just another metric a hospital system to potentially deduct pay from a physician. Stay calm , be nice and explain you are filing an expedited appeal.  You have the right to appeal the insurance decision. Of course  insurance doesn’t want you to appeal, makes it seem like a daunting task. When is the last time you had to write an official later? This is a game to the insurance industry  so lets make it a team sport. . Don’t be intimidated, you can handle this and I am here to help. Click here for example templates : https://mdfightsback.com/example-templates-to-appeal-insurance/
4. Follow up: Follow up with your insurance company to confirm receipt of your appeal and to check on the status of the review process. Keep records, not only include a copy of what you sent, but also when you sent it and when it reached the insurance payer, any who you have talked to. The hospital may need to send in updated clinical notes the case manager or rehab coordinator should be able to assist.